In past articles and our most recent article on trauma, we have mentioned the impact that Adverse Childhood Experiences, or ACEs, can have on an individual. While it wasn’t long ago that we figured it out, there is a great deal of research supporting the notion that one of the key contributing factors to substance abuse, mental health and other behavioral disorders is childhood trauma. Adverse Childhood Experiences, known widely as ACEs, are common and seemingly passive experiences that one may have as a child, that, when occurring repeatedly or in combination, have a devastating impact on a person’s development and long-term health.

When an Adverse Life Event takes place during one’s life in later adolescence or as an adult, the connection for the survivor to make between the traumatic experience and their future issues can be clear. Whether it’s a singular “Big T” trauma or a series of less severe “Little T” traumatic events, the link between these experiences and a person’s behaviors can often be made easily. For example, a 58-year-old man who recently went through a divorce, was laid off and then lost his house, might make the connection between these experiences and his increased drinking and isolation.

However, the link between ACEs and mental health or substance abuse issues that develop later in life can be more difficult, for a couple of reasons. For one thing, the mental health or substance abuse issues often don’t surface until years, or even decades, after the Adverse Childhood Experience occurs. What starts as general family dysfunction, divorce, neglect, or abuse may seem relatively normal through childhood and even into adulthood. The early signs and symptoms of a greater issue often manifest themselves as isolation, lack of trust, avoidance and other social and emotional issues before they ever develop into substance abuse or severe mental illness.

What are ACEs?

The notion of Adverse Childhood Experiences, or ACEs, began with the research of the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study. The study was conducted between 1995 and 1997 and studied nearly 17,000 Kaiser patients in a San Diego Health Clinic[1]. Patient health was studied through physical exams and surveys of current health and behaviors, while they also completed surveys about childhood experiences. What this groundbreaking study was looking at was the link – which was not understood at the time – between childhood trauma and physical, mental and emotional health later in life.

The ten childhood experiences they were looking at were:

Childhood abuse

1. Emotional Abuse

2. Physical Abuse

3. Sexual Abuse

Childhood neglect

4. Physical Neglect

5. Emotional Neglect

Household challenges

Growing up in a household were there was:

6. Substance abuse

7. Mental Illness

8. Violent Treatment of a mother or step-mother

9. Parental Separation/divorce

10. An incarcerated household member

Participants in the study were then given an ACE Score between 0 and 10, the total sum based on how many of the 10 types of adverse experiences they reported experiencing.

The Findings of the CDC-Kaiser ACE Study

The ACE Score, from 0 to 10, is used to assess cumulative childhood stress – now sometimes referred to as “Little T” trauma or by association with this study – a person’s “ACEs”. One of the clearest and most widely understood finding of the study was that Adverse Childhood Experiences (ACEs) are more common than one might think, or thought at the time. More than half (52%) of the participants from the original CDC-Kaiser study reported having at least one ACE, and more than 1 in 5 (20%) reported exposure to 3 or more ACEs, while another 6.2% reported 4 or more exposures[2].

The most prevalent of the categories of childhood exposure was substance abuse in the household (25.6%); the least prevalent exposure category was evidence of criminal behavior in the household (3.4%)[3]. Another finding was that the susceptibility of a person’s exposure to multiple ACE categories, as the relationship between single categories of exposure was significant. If someone reported any single category of exposure, the probability of exposure to any additional category ranged from 65%–93%; and then not surprisingly, the probability of more than two additional exposures ranged from 40%–74%[4].

The key finding of the study as it related to health outcomes, and which changed the way we understood childhood trauma, was that as one’s ACE Score increases, so does the risk for serious diseases and conditions, including:

Alcoholism and alcohol abuse

Illicit drug use

Depression and other mental health issues

Suicide attempts

Health-related quality of life

Smoking

Chronic disease

Heart and liver disease

Poor academic achievement

Poor work performance and financial stress

Risk for intimate partner violence

Multiple sexual partners

STDs and unintended pregnancies

Risk for sexual violence and intimate partner violence

The increased risk for these negative health outcomes and well-being are dramatic. Compared to someone with an ACE Score of 0, a person with an ACE Score of 4 or more is:

18 times as likely to have attempted suicide

Twice as likely to have had two or more weeks of depressed mood in the past year

Nearly 5 times as likely to have ever used illicit drugs

More than 11 times as likely to have ever inject drugs

More than 5 times as likely to be an alcoholic

How are ACEs Linked to Health Issues?

There is a large and growing body of research about how childhood stress and trauma affect brain development, brain chemistry and, thus, the regulation of the body’s emotional, stress and fear response systems are impacted. Repeated stress and activation of these systems of the brain dramatically alter the formation of myelinated axons and the amygdala, the part of the brain that activates the autonomic nervous system (ANS) and releases hormones like adrenaline and cortisol into the body. If you’re walking through the woods and see a bear approaching, or you see a kid walking into oncoming traffic, the activation of this system is very effective in increasing your heart rate, opening your airways, and increasing blood flow to your organs and muscles, and away from certain parts of the brain.

However, if the stress response system is activated every night by the sound of your dad coming home, or the sight of your mom reaching for a bottle of alcohol, your body and brain are hit with the same fight-flight-freeze response. The repeated activation of this system take a toll on your vital organs as well as your brain’s ability to regulate emotions and responses to triggers. When the body produces too much of, or stops producing, the natural chemicals to sooth or excite you, it is very common for people to turn to external stimuli to compensate this: depressants like alcohol and benzodiazepines, stimulants like cocaine and methamphetamine, or even behaviors like gambling and sexual intercourse.

Exposure to abuse and neglect also impact the prefrontal cortex, the part of the brain responsible for high level cognition and controlling impulse, and the nucleus accumbens, the brain’s pleasure-reward center which releases the body’s natural dopamine. The nucleus accumbens was first discovered in 1954 by two scientists when rats became addicted to pressing a lever that activated this part of the brain. The role of the nucleus accumbens and its connection to the amygdala and hippocampus[5] have great implications in the study of psychiatric disorders, substance abuse and addiction, obsessive compulsive disorder and Tourette’s Syndrome, and more studies are being conducted.

Dose-Response Relationship

The CDC-Kaiser study also found a “dose-response” relationship between ACEs and negative health and well-being outcomes across a person’s lifetime. A dose-response relationship is one where as the dose or intensity of the trigger increases, so does the intensity of the maladaptive behavior or response. For example, the more a person is exposed to abuse or neglect, the more severe the negative health outcomes will be.

Follow-Up Studies

Dr. Nadine Burke-Harris

One of the most notable cases of these results in action was the work of Dr. Nadine Burke-Harris, a pediatrician in San Francisco who was originally unaware of the CDC-Kaiser ACE Study. She noticed when she began working in a hospital in Bayview-Hunter’s Point, a low-income area of the city riddled with addiction and violence, that there was an abnormal number of children being referred to her for Attention Deficit Hyperactivity Disorder (ADHD). One of her colleagues made her aware of the ACE Study, which led her down a path of studying her patients’ exposure to trauma and how the brain and body were impacting their health. She subsequently started the San Francisco Center for Youth Wellness, where Dr. Burke-Harris made it routine to screen children for their ACE Score to better understand the risk factors of these youth across their lifetime.

See her TED Talk on How Childhood Trauma Affects Health Across a Lifetime:

Behavioral Risk Factor Surveillance System (BRFSS)

In 2009, the CDC began collecting annual ACE data through the Behavioral Risk Factor Surveillance System (BFRSS) from voluntary respondents telephonically. It is now the longest-running phone survey in the world. The BFRSS asks questions modified from the original ACE Study, from people across 32 states, using randomly dialed numbers. The data collected from the BRFSS are:

All ACE questions refer to the respondent’s first 18 years of life.

Abuse1

Emotional abuse: A parent or other adult in your home ever swore at you, insulted you, or put you down.

Physical abuse: A parent or other adult in your home ever hit, beat, kicked or physically hurt you.

Sexual abuse: An adult or person at least 5 years older ever touched you in a sexual way, or tried to make you touch their body in a sexual way, or attempted to have sex with you.

Household Challenges

Intimate partner violence:2 Parents or adults in home ever slapped, hit, kicked, punched or beat each other up.

Household substance abuse: A household member was a problem drinker or alcoholic or used street drugs or abused prescription medications.

Household mental illness: A household member was depressed or mentally ill or a household member attempted suicide.

Parental separation or divorce: Parents were ever separated or divorced.

Incarcerated household member: A household member went to prison.

The findings of the BFRSS are similar to that of the original CDC-Kaiser ACE Study:

More than two-thirds of the participants reported at least one adverse childhood experience

More than 1 in 5 reported exposure to 3 or more ACEs

Similarly, they also found a dose-response relationship with ACE Scores correlated to an increase in the following:

Myocardial infarction

Asthma

Mental distress

Depression

Smoking

Disability

Reported income

Unemployment

Lowered educational attainment

Coronary heart disease

Stroke

Diabetes

Treatment of Childhood Trauma

Understanding the role that adverse childhood experiences (ACEs) play in brain development and prevalence of addiction, mental illness and life-threatening diseases is a pivotal precursor to addressing these issues. Identifying and acknowledging the root of the issues is an important step in the recovery process, and only once a person can work through the lasting effects of exposure to Adverse Childhood Experiences can they truly recover. Because of the way these experiences embed themselves in our brain and body, the process of resolving them can take months or even years, but even the most complex trauma can be resolved with enough time and commitment.

Despite the acceptance of this research in the medical field, behavioral health professionals have been slower to integrate the identification and treatment of trauma into practice. It is important for someone who has been exposed to these adverse childhood experiences to find help at trauma-focused treatment programs like Roots Through Recovery, who utilize evidence-based approaches like Eye Movement Desensitization and Reprocessing (EMDR), Somatic Experiencing (SE), Mindfulness-Based Stress Reduction (MBSR), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and expressive approaches like music and sound therapy, trauma-focused yoga, and art therapy.

The word “trauma” is used widely today to refer to an experience that is damaging to a person’s psychological health, and as we’ve mentioned in previous articles, the magnitude of this experience is completely dependent on the individual. What most people outside of the behavioral health profession don’t know is that trauma can be categorized into two classifications: what are known as “Big T” and “Little T.”

BIG T TRAUMA

In general, the Big T variation of trauma refers to a single, traumatic event that can leave a survivor of the event with symptoms associated with Post Traumatic Stress Disorder, or PTSD. Experiences like sexual assault, serious injuries, violent attacks, and near-death experiences all fall under this category, and it’s now widely understood what kind of impact Big T trauma can have on a person’s life. People coping with the effects of a traumatic event, and may be suffering from PTSD, experience various symptoms including:

Re-experiencing

Flashbacks

Bad dreams

Frightening thoughts

Avoidance

Staying away from places, events, or objects that are reminders of the experience

POST TRAUMATIC STRESS DISORDER (PTSD)

Given the general public knowledge of trauma, you might find it surprising that it wasn’t until 1980 that the American Psychiatric Association recognized PTSD as a clinical diagnosis, when they added it to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). According to the U.S. Department of Veterans Affairs, the diagnosis was both controversial and groundbreaking as it suggested for the first time that the cause, “was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis)”. The introduction, research and development of the PTSD diagnosis has paved the way for more trauma-informed and trauma-focused care. You can read the latest criteria for diagnosing PTSD in the DSM-V below.

LITTLE T TRAUMA

Little T trauma is a very different thing though, because it includes virtually every other adverse life experience — each hardship and struggle that people deal with throughout life — that doesn’t fall under the Big T umbrella. Whether it’s a case of bullying, loss of friends or family members, or an emotionally abusive relationship, Little T trauma tends to be the tough situations that many people deal with on a daily basis that don’t necessarily result in a clear diagnosis of a lasting effect. Because trauma is subjective and depends entirely on a person’s resilience and perception, adverse life experiences include anything that could potentially result in trauma; not only the presence of a negative experience, but also the absence of a positive one.

Trauma is anything short of love.

-Unknown

Everyone handles trauma (in either variety) in different ways, and there is now a fairly prevalent belief — and the scientific backing to prove — that dealing with repeated Little T trauma can be just as significant as a single occurrence of its Big T counterpart. Much like experiencing a traumatic life event such as a natural disaster or surviving a serious car crash, experiencing repeated events that engage the body’s stress response system can alter the neural network, especially when these experiences take place in early childhood.

ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY

Thanks to a study conducted by the CDC and Kaiser Permanente Health in the late 90s, we now know the impact the Adverse Childhood Experiences, or ACEs, have on a person’s neurodevelopment and social-emotional-cognitive development, and as a result, their later in life health outcomes. In the ACE Study, seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.

What the study found was that a person with a higher ACE score was at significantly higher risk for substance abuse, mental health issues, intimate partner violence, and a host of health issues. Before the study was conducted and accepted by the medical and behavioral health community, these experiences that know refer to as adverse life events, adverse childhood experiences or Little T trauma, had been considered a normal part of life. Much like combat veterans returning home from war and being shamed or dismissed as being weak are now being treated for PTSD, these seemingly common but potentially damaging experiences are starting to garner the attention, empathy, or treatment that a Big T survivor might receive.

WHY ARE THESE IMPORTANT?

As mentioned above and in previous articles, exposure to trauma — whether it be Little T or Big T — can cause psychological (and sometimes physical) pain that often leads to destructive coping mechanisms, behavioral adaptations and health-risk behaviors. As a means to escape or numb the pain endured during the trauma, and the recurring discomfort that follows, survivors often turn to self-medicating with controlled substances. As with many addictions, it then becomes a vicious cycle that is generally only broken through proper trauma-focused treatment.

In all likelihood, every person will deal with some type of Little T trauma in their lifetime, and many will be no worse for the wear. But now that it has become recognized as a legitimate cause of maladaptive behaviors that can lead to mental health and substance use disorders, it can finally be treated and viewed on an even playing field with its “bigger” sibling.

In 2015, Michael Botticelli, the director for the Office of National Drug Control Policy stated:

“Medication-assisted treatment saves lives while increasing the chances a person will remain in treatment and learn the skills and build the networks necessary for long-term recovery.”[1]

So why is it that the use of medication-assisted treatment remains staggering and access is limited for those who need it?

When it comes to medication-assisted treatment, there is a whole host of misinformation and confusion surrounding its use and purpose, which leaves it rejected or ignored by the vast majority of treatment centers. Medication-assisted treatment is the use of legal, FDA-approved medications in combination with counseling and behavioral services provided by treatment professionals and family and peer support (Source: SAMHSA).

But for those who don’t understand the benefits or its place in treatment, it can seem simply as replacing one drug with another. Of course, that’s not the case for any accredited medication-assisted treatment programs, which is often the best option for some people looking to achieve long-term sobriety.

Here are a few of the debunked myths surrounding medication-assisted treatment.

MYTH: If you take medications like Suboxone, you aren’t really sober.

TRUTH: While it’s true that opioid replacements, such as Suboxone which contains Buprenorphine and Naloxone, act on the same receptors as heroin or an opioid, the medication attaches to these receptors but does not activate them, and also blocks other opioids from these receptors[2]. The combination of these two mechanisms helps control cravings in a person who is physically dependent on opiates without getting the person high.

MYTH: Medication-assisted treatment is for people who aren’t serious about their recovery.

TRUTH: In certain cases, even the most intensive counseling and behavioral treatments just aren’t enough to achieve sobriety and prevent relapses in the future. For these situations—particularly when opioids or severe alcohol use is involved—using medication-assisted treatment to neutralize the physiological effects may help someone attain this critical first step of recovery, allowing them to focus on the underlying issues and move forward in their recovery.

MYTH: It’s always better to just get people off of all drugs.

TRUTH: Although going “cold turkey” and just outright stopping the use of any substances is the ideal scenario for many, using medication-assisted treatment to ease the body away from its previous addiction can be both easier and medically necessary in some situations. “Ripping the bandage off” may seem preferable at the time, but it can also lead to complications, permanent damage, and even death if a person’s health is too fragile to handle the severity of the physiological repercussions.

MYTH: Medication-assisted treatment is just taking the easy way out.

TRUTH: If one accepts that addiction is a chronic disease, like diabetes or hypertension, then the use of medication should be understood to be a critical component of treatment in some cases. Like hypertension, if someone is able to address their condition by changing their lifestyle, such as their diet and physical activity, that is ideal; however, for some, that isn’t enough[3]. We wouldn’t shame someone with hypertension for taking Beta-blockers or ACE inhibitors, and addiction should be treated with the same understanding and compassion.

MYTH: People using medication-assisted treatment are less likely to stay sober.

TRUTH: When utilized correctly, medication-assisted treatment carries with it lower risk, and higher probability of success than solely doing counseling and behavioral services[4] for many people looking to address their addiction, stay in treatment[5], and remain sober for the long-term. One study found that patients who were still on an opioid agonist 18 months post-treatment, were twice as likely to be sober from opioid pain killers than those who were not (80% versus 36.6%).[6]

Figure Below. Abstinence Rate Exceeds 60 Percent in Long-Term Follow-Up of Medication-Assisted Therapy for Dependence on Opioid Pain Relievers Dependence on pain relievers dropped below 20 percent at 18 months, and below 10 percent at 42 months, after patients were stabilized on, and then tapered off, Bp/Nx. At all three follow-up points, patients who were currently engaged in opioid agonist therapy had markedly higher odds of positive outcomes. (Source: National Institute of Drug Abuse)

Like any form of treatment, medication-assisted treatment isn’t for everyone, and the decision to start these medications is made after consultation with a treatment team, and a thorough assessment is completed. If you’ve struggled with relapse and traditional treatment hasn’t worked for you, contact Roots Through Recovery or another certified provider to consult on whether it would be an appropriate course of action.

Alcohol abuse has far-reaching effects, not only on the individual but also for their family members and loved ones. It can be difficult and traumatic for a family member to see a person they care about struggle with alcohol addiction.

A family member’s substance abuse can lead to disagreements and tension in a family as family members adopt coping mechanisms to deal with the destabilized family dynamic. Family members may also have differing opinions on how best to help the person and protect the family from the negative consequences of the substance abuse.1

Understanding the effects of alcoholism on a family can help those with loved ones who are struggling with alcohol addiction to seek help if desired.

How Alcohol Abuse Affects Family Structure

According to the National Institutes of Health, there are several ways that alcohol abuse can affect a family.2 Often, this impact is determined by the type of family structure. For example:

Parents of young children: When a parent has a spouse who suffers from alcoholism, they may have to shoulder a significant portion of the family’s parenting responsibilities. This can put a tremendous strain on a parent or significant other.

Single-parent homes: When a child has a parent who struggles with alcohol addiction, they might often act as a “surrogate spouse” for the parent, taking on more and more household responsibility at a young age. The child may also have a significant amount of denial regarding the extent of a parent’s problem.

Parents of an adult with alcoholism: The child will often be dependent on aging parents, which can negatively affect their ability to mature emotionally. Doctors refer to this dynamic as codependency. The parent often enables the dependency of their child and might even unintentionally allow the addictive behavior to continue or worsen.

In addition to these known effects of alcoholism on immediate families, extended family members may also experience negative situations—commonly involving finances. People who struggle with alcoholism often have trouble meeting their financial responsibilities, and family members may attempt to compensate for these shortcomings or protect the individual from the consequences of their actions.

Help for Those Whose Family Member Is Experiencing Alcoholism

Having a loved one struggle with alcoholism can greatly affect a family’s ability to function normally. Family members may adopt different roles, and they may have difficulty communicating. This can lead to friction, tension and disagreements related to their family member. Some may be in denial over the person’s problems, while others may be frustrated or concerned over a person’s drinking and how it jeopardizes their safety and the safety of others.

Support for Family Members

Many treatment centers offer support for those who have a family member struggling with addiction. This can be in the form of assistance with planning an intervention, therapy for the family or group therapy with both the individual and the family. Support groups, both in-person and online, are also available to help a person learn more about alcoholism and its effects and suggestions for how to help a person struggling with alcohol addiction. Through education and supportive services, families can get the help they need.

It can be difficult to determine when socially acceptable drinking crosses over the line and becomes a drinking problem. Having a drink, or two, or more, is almost always socially acceptable. Virtually every celebration we attend—weddings, birthday parties, holiday gatherings—offer alcohol. We’re inundated with advertising portraying people having a good time while drinking.

We drink to celebrate, and we drink to relax. How do we know when socially acceptable drinking turns into a full-fledged drinking problem?

The Stages of a Drinking Problem

A drinking problem can start with the development of tolerance, which is where you have to drink more and more alcohol to achieve the desired results. This overconsumption can then develop into dependence, where withdrawal symptoms appear if alcohol is decreased or stopped.

Heavy alcohol consumption that moves from tolerance to dependence often leads to the development of an addiction. Alcoholism, known clinically as an alcohol use disorder, is when a person continues to drink despite negative effects on their health and well-being, and often despite a desire to stop.

Alcoholism looks different person to person. Some people drink excessively only in the evenings, and others take their first drink in the morning and continue throughout the day. Others drink only on occasion, but those occasions always involve binge drinking large quantities of alcohol to the point where they black out.

Recognizing the Signs of a Drinking Problem

Alcoholism has a fairly consistent set of signs that can help you determine if your drinking has progressed from occasional overindulgence to problem drinking:1

You drink more alcohol or for longer periods of time than you intended.

You’ve felt more than once that you need to drink less alcohol, or you’ve tried to stop drinking.

You spend significant amounts of time drinking or recuperating from hangovers or other effects of alcohol.

If you have experienced two or more of these situations within 12 months, it may be time to face the truth and seek professional help.

Getting Help for a Drinking Problem

If you think you might have an alcohol use disorder, consider seeking professional addiction treatment to reclaim your life. To ignore the signs of a drinking problem is to put yourself at risk for more serious consequences to your health, such as cirrhosis of the liver or neurological complications.2 The impact of a drinking problem on family and work life can also be devastating.

Treatment for a drinking problem works, and it can work for you. Reach out to a high-quality addiction treatment center and get the help you need.